Does Clinical Anatomy deserve another 25 years? Reflections on how Clinical Anatomy has changed in the past quarter century

Abstract

No absract.

The title of this Editorial is inspired by the one written by Ralph Ger (AACA) and Ray Scothorne (BACA), the Founding Editors of Clinical Anatomy (Ger and Scothorne,1988) when our Journal began 25 years ago. They highlighted three trends:

• 1
  The time available for study of anatomy has been greatly reduced…
• 2
  There has been a decline in the proportion of clinically qualified anatomists…
• 3
  Developments in many branches of medical practice depend on increased knowledge of specialized anatomy…

The purpose of this Editorial is to first examine whether these trends have changed and whether new trends have emerged in the quarter century that Clinical Anatomy has been published, and then look at other advances that have been published in our Journal.

Pertaining to the first trend, Drake et al. (2009) showed that total hours in gross anatomy (and other anatomical disciplines) decreased since earlier surveys dating back to 1955; specifically decreasing from almost 350 total hr in 1955, and just below 200 hr when Clinical Anatomy was first published in 1988, to 149 hr in 2009 (see fig. 5 in Drake et al.,2009). The “time available for study of anatomy” continues to be reduced and, in some medical schools, removed. There is evidence (for example, see Moxham and Plaisant,2007) that medical students still strongly believe that anatomy is critical for their clinical studies.

Figure 1. We take Clinical Anatomy to the ends of the earth. Stephen Carmichael at Lands End (Cornwall, England), June 2011.

As for the second trend, I believe that the considerable difference in compensation for anatomists compared to practicing clinicians discourages many clinicians from being full-time anatomy educators, at least in the United States. However, in many anatomy courses, clinicians (mainly surgeons and radiologists) interact with medical students in the anatomy lab for a session or two. But as long as the compensation levels are not comparable, the decline in the proportion of medically qualified anatomists will continue.

As for the third trend, it has been thoroughly documented in the pages of Clinical Anatomy that developments in many branches of medical practice have depended on increased knowledge of specialized anatomy. Literally, the way we look at the anatomy of the human body has changed. This is most obvious in the new imaging techniques that have rapidly evolved in the last quarter century and minimally invasive surgical techniques that provide decreasing and often magnified fields of view.

There is no question that ultrasound has become a mainstay of imaging during the past 25 years, as have computed tomography and magnetic resonance imaging (MRI). Mariappan et al. (2010) took MRI a step further with MR elastography, a technique that detects differences in tissue stiffness, often indicative of pathology. Muehleman et al. (2010) are developing a new imaging method that promises to better show defects in articular cartilage. This has the potential to be very important in diagnosing arthritis, an affliction that will become more prevalent in our aging population.

Minimally invasive surgery has become much more common over the last 25 years. A search on the web site for Clinical Anatomy (wileyonlinelibrary.com/journal/ca) for “endoscopy” and related terms yielded 199 hits, most of those for articles published in our Journal in the past few years. One example is Moran and Gostout (2009), who reviewed natural orifice translumenal endoscopic surgery, often referred to by the acronym NOTES. This is a type of minimally invasive surgery that avoids a skin incision.

Human anatomy has not changed since our Journal was first published (actually, it has not changed much for thousands of years!), but there have been many other changes. Students have changed: there is a new generation of learners (see for example, DiLullo et al.,2011). Curriculum has changed. Now it is much more integrated, student-centered, and involves active learning more than before. This has been a conscious response to changes in health care delivery that requires a different type of physician. Anatomists have become content experts who direct the learning process. Much more is taught in anatomy courses now than merely morphology, e.g., professionalism and teamwork (Pawlina,2006; Gregory et al.,2009). Assessments of students in anatomy courses have broadened. In addition to anatomic knowledge, other important domains are assessed including critical thinking skills, communication skills, and professionalism (Camp et al.,2010). The environment has changed. The anatomy professor, the lecture, and the textbook are no longer the exclusive source of anatomic information. Students are much more responsible for their own learning and this is generously supplemented with web-based materials.

It is also clear that residency program directors thought that residents needed to begin their clinical training more proficient in clinical applications, general anatomic knowledge, and cross-sectional applications (Cottam,1999). In 1999, Cottam saw that the majority of anatomy departments were increasing the emphasis on imaging techniques, clinical correlation, and cross-sectional anatomy. This trend has continued, with the addition of viewing anatomy in other planes since modern image processing can do this “on the fly.” Interestingly, the article by Cottam (1999) is the most frequently cited paper in the 25-year history of Clinical Anatomy!

In many schools, gross anatomy is no longer a free standing course representing anatomy-for-anatomy's-sake, but rather is now strongly clinically oriented. It belongs and is part of the curriculum that is structured to achieve the mission of the professional school. In several programs, anatomy is extended throughout the curriculum as part of the longitudinal objectives in harmony with clinical courses (Carmichael and Pawlina,2004).

On a different topic, Clinical Anatomy has expanded historical articles through the Glimpse of Our Past category. In my opinion, the most significant are a series of articles illuminating the dark past of anatomists during the Third Reich. Of these scholarly articles, the series by Sabine Hildebrandt (2009a,b,c) is particularly comprehensive. Articles in Clinical Anatomy on this topic were even noted in Science by Pringle (2010).

Clinical Anatomy began publishing Special Issues in 2006. These are filled with timely reviews, all on a related topic. The first Special Issue covered the Visible Human projects in the USA, China, and Korea (Seifert and Carmichael,2006). This was followed a few months later by one dedicated to professionalism as applied to anatomy education, one of the first basic science journal issues on this topic (Pawlina,2006). Other Special Issues have followed (Anderson and Loukas,2009; Porta,2011; Richards,2012).

Finally, Clinical Anatomy provides a forum for discussion of human variation. This is best exemplified by Bergman (2011) and the six Letters to the Editor that follow his article. The last issue of each year includes our annual Compendium of Anatomical Variants.

So if we ask the question put forward a quarter of a century ago, “Does clinical anatomy need, or deserve a new journal?” I hope the reader agrees that enough evidence has been put forward to respond in the affirmative. I can only hope that the next 25 years will be as productive in moving our discipline and our Journal in a direction that will continue to establish Clinical Anatomy in a leadership role!

Acknowledgements

The author gratefully acknowledges the helpful input from several academic colleagues. The author also thankfully acknowledges the considerable contributions of the many authors, reviewers, Editors and support personnel with whom the author had the privilege of working for the past 12 years.